- As the Malawian government takes stock of its anti-AIDS treatment programme, health officials have been faced with the question: how does a poor country with a serious epidemic and an overburdened health system provide indefinite care for up to 200,000 people living with HIV?
In a recent article in the medical journal The Lancet, three researchers involved in the country's treatment programme said the answer lies in sticking to a simple public health approach.
One of the authors, Dr Erik Schouten, who is also the health ministry's HIV/AIDS coordinator, told PlusNews that Malawi could not afford to follow wealthier countries like South Africa, that use advanced laboratory technology to monitor patients.
According to the Lancet report, the unmet need for treatment remained "massive", and an estimated 90,000 people living with HIV/AIDS would become eligible for the life-prolonging medication every year.
"The only way to address this [need for ARVs] and get the biggest impact is to keep it simple ... we have to choose what would be good for many [rather than] what would be better for a few," Schouten said.
One way of doing this, the authors stated, was for Malawi to continue scaling up use of the current first-line regimen only, and provide other first-line and second-line drugs in only a few centres, as priority should be given to those not yet receiving the drugs.
People living with HIV/AIDS begin treatment on first-line drugs, and only need second-line ARVs when they become resistant.
"Malawi's finances are not limitless. Other first-line drugs cost an average three times more per patient ... and second-line therapy costs eight times more," the Lancet report found.
The southern African country is also struggling with a severe shortage of skilled health-care workers: 64 percent of their nursing posts are unfilled, and the number of doctors practising is only a sixth of the total recommended by international guidelines.
A much-heralded US$273 million 'Emergency Human Resources Plan' covering the next six years should bring welcome relief and have a "positive effect" on the rollout, Schouten commented.
But in the meantime, clinics and health-care workers are beginning to feel the strain since the number of patients eligible for the drugs are rising every month.
Despite internal and external pressure to use advanced laboratory technology to assess patients on treatment, Schouten and his colleagues suggested that this would "weaken rather than strengthen general laboratory services", and restrict the scaling up of treatment to urban areas, neglecting poorer, rural areas.
"We cannot support this unless the technology for measurement of viral load and CD4-counts become cheaper, more straightforward, and more user-friendly".
Over 40,000 HIV-positive Malawians are now receiving free anti-AIDS drugs from public health facilities, and if the new scale-up plan for 2006-10 "goes perfectly", 245,000 people will have started treatment by 2010.
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